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| Beware of “Friendly Prescribing!” |
| By Jeffrey E. Keller MD |
| Published: 12/01/2014 |
Imagine that you are a healthcare provider in a jail medical clinic. One of the jail nurses comes to you and says “Will you call me in a prescription for my hypertension meds? I have no more refills and my doctor charges $100.00 for a visit just to get more!” Or perhaps it is a detention deputy who asks, “Can I get a few Ambien from you? This shift work kills me and I need them occasionally.” Or “Can I get some Augmentin? I have Bronchitis.” This is not just a phenomenon in corrections. No matter where I have worked in my career, co-workers have asked me for prescription favors like this. This has happened in every ER I ever worked. It has happened in urgent care clinics. I have been called at home by family, friends and even casual acquaintances asking for prescriptions for themselves–or even for family members! I suspect that this is a universal phenomenon in health care. I don’t know about you, but when this happens, I feel like I am on the spot. Even though I know that I probably shouldn’t give out prescription medications in this manner, these are co-workers and friends. Giving them the prescription would be easy for me. And refusing it would seem to be an insult. Take the guy who wants a refill of his hypertension meds. How do I say to him “No” without implying “Even though this would be easy for me, I’m going to make you pay the $100.00 to your doctor because, well, I just don’t like you that much?” The bad news here is that this practice truly is bad—on several levels that we will review. It is bad medicine. It is bad ethics. It is bad medico-legal practice. The good news, though, is that there is a way to properly handle these friendly medication requests gracefully and without offending anyone. I will discuss that later. First, though, here are a few of the many reasons that giving out friendly prescriptions is a bad and dangerous medical practice. Friendly Prescriptions are Bad Medicine It is bad medicine to dispense prescription medications without examining the patient. If you have not done a formal history and physical exam, you are prescribing blind—you do not know for sure whether the patient really has the condition they are telling you about. Take, for example, the patient who wants a refill of a simple hypertension medication, let’s say lisinopril. Would it make a difference to you if you actually took the patient’s blood pressure and found that it was 240/130? Would a simple lisinopril prescription be appropriate in that case? In fact, that is why the outside doctor insists on seeing the guy once in a while—so she can make sure that the medication is actually doing what it is supposed to do—lowering the blood pressure—as well as checking for those insidious complications that people with hypertension sometimes develop. That is just good medicine. For you to circumvent that practice—well, that’s not so good. Or consider the patient who asked for a specific antibiotic (Augmentin) for “bronchitis.” How do you know without an examination whether this friend really has a viral chest cold and the antibiotic could not possibly help? Or whether instead they have wheezing and would benefit more from albuterol instead? Also, all prescription medications have side effects and potential negative effects. This is the reason these medications are not over-the-counter. The prescription of these medications involves the weighing of potential benefit vs. potential harm, and one job of the medical prescriber is to explain this to the patient. For example, does the patient who asked for Ambien know that Ambien is a controlled substance (DEA schedule IV, the same as benzodiazepines)? Does he know that Ambien has a particularly high side effect profile, which includes blackouts, and even suicide? That the FDA recently required manufacturers to reduce the dosage recommendations because of this? Does he understand that he should never, ever drink and take Ambien because this is quite dangerous (though commonly done to get high)? And are you really going to take the time to explain all of this to him while you are standing in a public hallway? Similarly, does the friend who asked for Augmentin know that, according to the CDC, almost all “bronchitis” is viral and no antibiotic should be prescribed? Or that one out of six people who take Augmentin develop diarrhea? Are you going to explain this to him during the “friendly prescription” request encounter? Probably not. The bottom line is that without an exam, you are not sure, really, of the diagnosis, or whether the prescription is the correct one. And you probably will not fulfill your responsibilities as a prescriber to explain diagnosis, treatment and potential complications of therapy. So you are practicing bad medicine. And since you did not do a history, a physical exam or discuss treatment, your chance of getting it wrong and having a bad outcome has gone way up, which leads us to our next point. Friendly Prescriptions are Bad Legal Practice Here is the single most important thing that you need to know about the medico-legal risk of friendly prescriptions: Your malpractice insurance policy does not cover them! Why not? Because these people are not your patients! You did no physical exam. You did no history. You generated no medical chart. You did nothing that would identify them as patients of yours—so if something does go wrong, you are on your own. If you don’t believe me, call your insurance company and check! So by giving “friendly prescriptions,” you are now in a position of practicing bad medicine with a high risk of a bad outcome on a population not covered by your malpractice insurance. Hmmm. You might think, “I’m OK! These are my co-workers and friends! They would never sue me!” Well, you might think this but you would be wrong. The annals of malpractice are filled with such lawsuits. Your co-worker and friend might say thank you at the time for the freebie, but when they have the stroke because you missed the 240/130 blood pressure or they have the allergic reaction to Augmentin and their skin falls off, they will suddenly remember that, Hey! That wasn’t proper medical practice! So here is the obligatory medico-legal horror story that I heard about through Risk Management Monthly. An ER doctor is approached by one of the ER nurses, who tells him that her husband is struggling with depression. She asks the doc if he will write a prescription for Zoloft for her husband—just enough for a month until she can get him into a psychiatrist. The doc writes the prescription and . . . two weeks later, the husband commits suicide. The widow now sues the ER doc for malpractice, alleging that the ER doc failed in his responsibility to inform her that one well recognized complication of Zoloft is that it may increase suicide risk early on, especially in adolescents and young adults, like her husband. Also, he failed to take a history and do a mental health examination, which would have revealed that the husband was suicidal and needed to be hospitalized. Needless to say, the ER doc’s malpractice company refused to cover this event. This was not one of his patients. There was no history or exam. There was no chart. He had never even met the guy! The ER doc was on his own. The moral of this story is: No Good Deed Goes Unpunished. And remember the guy who asked for a prescription for Ambien to help him with his shift work? The final essential legal point you need to know is that it is illegal in most states (42 out of 50, to be exact) to prescribe controlled substances without physically examining the patient . Here, for example, is a summary of New York’s policy on prescribing controlled substances . Note this quote: “A practitioner must examine a patient every time he/she prescribes controlled substances.” So giving out a friendly Ambien prescription is not only bad medicine, it is illegal! The Board of Medicine in many states, including my home state of Idaho, have also formally condemned the practice of giving out any prescriptions, even those that are not controlled substances, without an examination. Even though it is not illegal, if the Board finds out that you have been doing it, you can be sanctioned or otherwise disciplined. Good News! You Can Prescribe “Friendly Prescriptions” Properly! As you probably have gathered already, the main problem with friendly prescribing is not doing a history, a physical exam and creating a chart—in other words, not treating the friend like a real patient. So the first step on the way to do these prescriptions right is to create a chart and treat the person like a patient. You don’t have to charge your co-worker or friend a fee, so if your friend is asking this favor because of a lack of insurance or funds, by all means, don’t charge! But do generate a chart and in every other way treat them like a real patient. The way it works is this: a friend calls you up and asks for a friendly prescription. You would say, “I’m happy to, but you need to come see me. The State Board of Medicine requires it. I won’t charge you, but you do need to come by.” When you start to do this, you may be surprised how few actually show up. Most (I guess) turn to other, less stringent, friendly prescribers. Friendly Prescriptions–Other Considerations There are a couple of other things you should consider in the matter of friendly prescriptions. The first is exactly which prescriptions you are willing to prescribe in a friendly fashion and which you are not. For example, if a friend asked you to prescribe phentermine to help with weight loss, would you do it? I personally won’t, because phentermine is a DEA schedule 2 amphetamine with a high abuse, addiction and side affect profile. Also, amphetamine driven rapid weight loss is controversial and, at best, requires frequent monitoring. Are you willing to commit to all of that? Not me. I have decided that I will not issue any “friendly” prescription medications that I would not prescribe in my regular practice. For me, this includes sleeping aids and almost all controlled substances. Here’s another situation to give some thought to: What about other chronic disease states that should be followed, well, chronically? Take the co-worker who asks for a refill of hypertension meds. Let’s say you do an exam and document that they look ok and give them a 3-month refill. What are you going to say when they ask for another refill 3 months from now? Are you going to take them on as a chronic long-term patient? If not, you may want to make this clear: “Since you are in a bind, I will refill this prescription once, but it is very important that people with high blood pressure are followed in a systematic fashion, and I don’t do that in this clinic. So you really need to get back in to see your regular doctor.” How about anti-depressants or other psych meds? Smoking cessation medicines? Kenalog shots or other steroids? All of these need to be considered. Finally, since you are going to do an exam and generate a chart on these friendly prescription people, the facility where you practice may have an opinion as to how this is to happen. For example, the administration at one of my jails, after considering the medico-legal risk, the hassle of how and where to store charts and the strain of deciding what could be prescribed and what could not, decided in the end that they did not want the jail employees seeking friendly prescriptions at the jail medical clinic—at all. Jail employees are told to see their own doctors or the established workman’s comp clinic. The only exceptions are true emergencies. It probably would be worthwhile to discuss “friendly prescribing” practices at your facility! Summary
Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog Other articles by Keller |
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